Information Collection

Form 1095-A- Health Insurance Marketplace Statement

IC 213666 under ICR 202408-1545-001 · OMB 1545-2232.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1095-A Form 1095-A- Health Insurance Marketplace Statement	Form
Form 1095-A Health Insurance Marketplace Statement Form 1095-A- Health Insurance Marketplace Statement	Form
i1095-a--2023-00-00.pdf	Instruction
i1095-a--2023-00-00.pdf	Instruction
1095-A Health Insurance Marketplace Statement f1095-a--2024-00-00 (draft).pdf	Form
1095-A Health Insurance Marketplace Statement f1095-a--2024-00-00 (draft).pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Form 1095-A- Health Insurance Marketplace Statement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 26 CFR 1.36Bâ5

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1095-A				Yes	Yes	Fillable Fileable
Instruction					Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title: IRS 24.030- Individual Master File, IRS 24.046-Customer Account Data Engine Business Master File, and IRS 34.037- Audit Trail and Security Records System

FR Citation: 80 FR 54064

Number of Respondents: 15

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,250,000	3,250,000
Annual IC Time Burden (Hours)	16,250	16,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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